Group Individual

Personal information Test Interpretation

Test Results Summary
Diagnostic impression Recommendation
Personal Information

Create client’s personal information based on case history data

Name:
Age/Civil Status: Sex:
Birthdate:
Birthplace:
Educational Attainment:

Source of Referral:
Reasons for Referral:

Case History

Mr. Pikachu is a 22 year old Filipino who was born on September 9, ****. He is currently
residing at Matapang Street, Quezon City and is living with his family. He is a third year
engineering student at CEU merge class.

Mr. Pikachu was referred by Dr. Caterpie for a neuropsychological evaluation in order to rule-out
or confirm the presence of Major Depressive Disorder.

It must be noted that all background information in this evaluation are based on the information
given by Mr. Pikachu and his mother during the assessment.

Mr. Pikachu was born via caesarean section on the year ****. He reported to have been
described by his parents as a curious baby as he reached the different developmental milestones
of his life. Also, he considers himself to have grown normally with no physical defects from birth
till present. His academic performance was described as above average; he was a consistent
honor student during his elementary and high school years. However, during college, his
performance decreased from above average to average ratings. On the other hand, his
relationship with his peers, classmates, and teachers were reported to be generally fine as no
significant disruptive experiences were reported by Mr. Pikachu during the interview.

Currently, he described himself as someone who is in need of exercise to improve his physical
health. Additionally, his mental health was reported to be healthy at times but he is afraid that he
might experience the same depressive episodes again. In relation to this, he is taking Arcalion
and Brintellix to address the symptoms of depression; these medications were prescribed by his
attending physician Dr. Wazowski from Monster University Medical Hospital since the first
week of October, 2017.

With regard to Mr. Pikachu’s family history, an existing medical history of asthma from his
mother’s side was reported. Also, he stated that his mother, older brother, and older sister
experienced depressive episodes at certain stages of their lives which were similar to the stage
Mr. Pikachu is currently in. Both parents are still alive. However, he only speaks to his mother as
he received a lot of verbal punishment from his father growing up. He was the youngest child
with two older brothers and an older sister. In relation to this, his relationships with his siblings
were described to be generally fine by Mr. Pikachu.

Mr. Pikachu is currently in a relationship with a girl he met from an online game. She was his
first girlfriend and their relationship started last September 2016. Their relationship was
described to have a lot of romance and was very sweet in the beginning, during the honeymoon
stage. However, Mr. Pikachu’s sweetness was described to become more relaxed after a few
months. This resulted to their break-up last August 2017 which triggered Mr. Pikachu’s recent
depressive symptoms until they got back together by the month of October within the same year.
These events prompted Mr. Pikachu to seek professional help as he is afraid that he might
experience the same depressive symptoms again.

Mr. Pikachu initially experienced depressive symptoms in the month of September last 2016.
According to his reports, it was originally experienced during a summer semester where he
suddenly felt separated from his classmates. Additionally, he described that his academic
performance declined and that he felt overshadowed by his other classmates. As a response to the
given circumstances, he then began to go on his own, spending time in a nearby computer shop
during break times and would directly go home after his last class.

Eventually, a concerned classmate referred him to a professor for help. Then, a staff from their
school guidance office also conducted an interview. These referrals lead to an appointment with
the guidance office and a doctor from their school clinic who suggested that he needs to see a
psychiatrist. On September 2016, he met a psychiatrist from the Walt Disney Medical where he
had an interview session. In addition to this, his classmate also referred him to a psychologist
within their school. He failed to report the details related to the said referrals and interviews as he
claimed to have forgotten them all. After the appointment with a psychiatrist where he allegedly
wasn’t able to receive assessment results or interventions the reported symptoms eventually
waned down until a relapse occurred between the months of June and July 2017.

Mr. Pikachu reports to have experienced severe forms of depressive symptomatology in June or
July 2017. However, he failed to identify a specific trigger for such experiences. Nonetheless, he
confirmed that he recently felt sad most of the day. Also, his interest in previously enjoyable
activities was also affected. In relation to this, he slept a lot and had a hard time getting up from
bed. Furthermore, he reports to have experienced feelings of worthlessness, diminished ability to
concentrate, and had contemplated on committing suicide within the past month. Conversely, no
attempts of suicide or any forms of self-harm were reported during this time.

On the other hand, the mother of Mr. Pikachu supported his reports about the first time he
experienced the said depressive symptomatology last September 2016. This time, Mrs. Ash
identified an event that could’ve triggered her son’s depression; Mr. Pikachu was transferred
from Management Engineering course to an Engineering course within the same university but
this transfer separated him from the rest of his friends. Mrs. Ash also noticed that these
depressive symptoms eventually waned down, the reason why they weren’t able to do a follow-
up on the interview he had with his psychiatrist last September 2016.

However, by August 2017 she noticed that Mr. Pikachu had constant fights with his girlfriend
almost every night. She added that they decided to end their relationship within the same month
and by the month of September 2017, Mr. Pikachu began to again overtly manifest symptoms of
depression. Additionally, he posted that he satisfied five out of nine symptoms of depression at
Facebook. Also, upon immediate confrontation, Mr. Pikachu talked about suicidal ideation and
other causes he identified to have triggered the depression which includes her mother’s strict
requirements for academic performance, existing family dynamics which was described as less
expressive, and his resentment towards his father.

Behavioural Observation
Mr. Pikachu went to the evaluation appointment wearing casual clothing. He was accompanied
by his mother. He was very cooperative all throughout the entire assessment procedure and was
able to perform and accomplish different tasks without losing focus or interest. No irrelevant
behaviors and gestures were observed during the entire assessment. However, he expressed
fatigue during the final phase of the intelligence test but eventually agreed to continue the
assessment after a short break. Lastly, expressive and receptive language ability were intact
during the entire assessment procedure.

Tests Results and Interpretation

A. General Intellectual Ability

WAIS-IV – Weschler Adult Itnelligence Scale

Composite 95% Confidence Percentile Qualitative

Index
Scores Interval Rank Description
Verbal
105 99-110 63rd Average
Comprehension
Perceptual
105 99-111 63rd Average
Organization
Working
111 104-117 77th High Average
Memory
Processing
124 113-130 95th Superior
Speed
Full Scale IQ 112 108-116 79th High Average
B. Affective and Personality Domains
PAI – Personal Activity Intelligence
Scale
Inconsistency (INC)
Infrequency (INF)
Negative Impression (NIM)
Positive Impression (PIM)
Somatic Complaints
(SOM)
Anxiety (ANX)
Anxiety-Related Disorders
(ARD) 46
Depression (DEP)
Mania (MAN)
Paranoia (PAR)
Schizophrenia (SCZ)
Borderline Features (BOR)
Antisocial Features (ANT)
Alcohol Problems (ALC)
Raw (T) Description Score Interpretation
Score Score
Validity Scales:
Measures the subject’s
8 58
consistency in answering
Measures random responding,
3 51 indifference, carelessness,
confusion, or reading difficulties
11 84 Measures possible malingering
Measures possible
5 27 presentation of a very favorable
impression
Clinical Scales:
Measures preoccupation
33 72 w/health matters & somatic
complaints
39 71
Measures phenomenology &
observable signs of anxiety
Measures symptoms &
81 behaviors specific to anxiety
disorders
Measures symptoms &
52 90 phenomenology of depressive
disorders (unipolar)
Measures the affective,
cognitive, & behavioral
32 60
symptoms of mania &
hypomania
Measures symptoms of
paranoid disorders & more
46 82
enduring characteristics of
paranoid personality
Measures symptoms relevant
36 78 to the broad spectrum of
schizophrenic disorders
Measures attributes related to
borderline level of personality
functioning, indicating unstable
57 89 & fluctuating interpersonal
relations, impulsivity, affective
lability & instability, &
uncontrolled anger
Measures history of illegal acts
& authority problems,
24 62 egocentrism, lack of
empathy/loyalty, instability &
excitement-seeking behavior/s
4 49 Measures problematic
 consequences of alcohol-use &
features of alcohol-dependence
Drug Problems (DRG) Measures problematic
6 54 consequences of drug use
(prescription & illicit) & features
of drug dependence.
Treatment Consideration Scales:
Aggression (AGG) Measures characteristics &
attitudes related to anger,
hostility & aggression; this
43 83 includes a history of aggression
(verbal or physical)& attitudes
conducive to aggressive
behavior
Suicidal Ideation (SUI) Measures suicidal thoughts-
ranging from hopelessness
31 107 through general & vague
thoughts of suicide, to thoughts
representing distinct plans for
the suicidal act
Stress (STR) Measures the impact of current
or recent stressors in the areas
10 59 of family, health, employment,
finances, & other major life
areas
Non-support (NON) Measures a lack of perceived
social support (considering
16 80
both the level & quality of
available support)
Treatment Rejection (RXR) Measures attributes
theoretically predictive of
interest & motivation to make
changes of a psychological/
emotional nature: feelings of
1 20 distress & dissatisfaction,
willingness to participate,
recognition of need for change,
openness to new ideas & a
willingness to accept
responsibility for actions
Interpersonal Scales:
Dominance (DOM) Measures the extent to which a
person is controlling and
independent in personal
relationships. Conceptualized
18 45
as a bi-polar dimension, with a
dominant interpersonal style at
the high end and a submissive
style at the low end.
Warmth (WRM) 10 26 Measures the extent to which a
person is supportive &
empathetic in personal
relationships; conceptualized
as a bi-polar dimension w/ a
warm, outgoing interpersonal
 style at the high end & a cold,
rejecting interpersonal style at
the low end

BDI-II (43) - Becks Depression Inventory

BAI (27) Becks Anxiety Inventory

DASS (D – 38, A – 24, S – 27) – Depression Anxiety Stress Scale

Structured Clinical Interview

Mr. Pikachu reported to be in a depressed mood most of the day. Also, he exhibits diminished
interest on previously interesting activities. Likewise, he tends to sleep a lot as compared before.
Similarly, he felt weak almost every day due to loss of energy and fatigue. Furthermore, he felt
worthless and is experiencing recurrent thoughts about death. Moreover, his ability to think
clearly and concentrate has diminished over the past weeks. These symptoms were reported to
have significant distress on social and scholastic functioning. In relation to this, such experiences
are not attributable to physiological effects of substance or other medical condition.

In addition to this, he is also experiencing symptoms of anxiety during the course of depression
as he fears the worst and is experiencing fear of losing control over himself. Also, there would be
times where he felt unusually restless and unsteady.

On the other hand, no forms of manic and psychotic episodes or symptoms were reported by Mr.
Pikachu. Additionally, the signs and symptoms currently manifested by Mr. Pikachu does not
satisfy any form of personality disorder from different clusters. In relation, observation and
reports of Mrs. Ash (Mr. Pikachu’s mother) complemented such reports provided by Mr. Pikachu
about the absence of manic and psychotic symptoms.

Summary

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Diagnostic Impression

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Recommendations

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Thank you for giving us the opportunity to work with Mr. Pikachu. Should you have any
questions regarding this report or if we can be of further assistance, please do not hesitate to
contact us at the ****** *******, at cell phone number, (632) ***-****.

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